Panel 9

Triple A takes hold in Oman

Photo: A woman reviews her child's growth chart with a volunteer nutrition
adviser, part of a community-based effort to promote better child nutrition
in Oman.

Over the last 27 years, Oman has made great strides in child survival
and development. Child mortality dropped from 215 per 1,000 live births
in 1970 to 25 in 1995. School enrolment, particularly among girls, has increased
dramatically. Revenues from oil have pro vided an economic foundation-Oman's
GNP per capita in 1995 was $4,820 - but these gains would not have been
pos sible without the Government's com mitment to improving people's lives.

Progress has been slower, however, in terms of child nutrition. The Ministry
of Health, with support from UNICEF, has been working to address this challenge
since 1993. To improve children's nutritional status, a community-based
programme of growth monitoring, counselling and nutrition education was
devised. A particular focus is 105 villages of Al Dakhiliya, an arid, rocky
region in upper-central Oman where a 1995 survey found that nearly one third
of the children under the age of five were underweight.

The results to date are impressive. Since the project's inception, there
has been a significant drop in the number of underweight children, according
to an appraisal in 1996. Later the same year another appraisal described
the project as well focused, effectively managed and clearly build ing a
momentum towards nationwide nutritional improvement. Motivation, commitment
and participation were high among mothers and community volunteers. And
women enjoy the op portunity the programme offers to meet together and find
common ground in helping their children grow better.

The driving force of the programme is called 'triple A': three consecutive
steps in a problem-solving cycle of Assessing the problem, Analysing its
causes and initiating Actions to improve children's nutrition. Triple A
is an iterative process that repeats the cycle of reassessment, re-analysis
and re-action, leading to regular modifications and im provements in the
approaches taken.

True to this model, the people of the small villages and nomadic or semi-nomadic
settlements of Al Dakhiliya were involved from the very start, attending
meetings to identify the problems, discuss solutions and select from among
themselves the volunteers who would be central to the effort.

Every month throughout the region, at public meetings or during visits
to homes, these volunteers weigh children and chart their growth, referring
severely underweight children to health care centres. They advise families
on how to feed children and to improve caring practices, on how to keep
children healthy and manage illness when it occurs and on how to space births.
They also reinforce other public health activities, encouraging pregnant
women to reg ister early for antenatal care, for example, and helping in
community immunization cam paigns and national health days.

Regional trainers were brought in to teach the volunteers about the incidence
and causes of malnutrition, and how to improve and support appropriate feeding
and caring practices, using the triple A methodology to solve problems.
A programme coordinator at the regional level links the communities with
programme support structures at the national level and supervises, monitors
and trains trainers. There are programme coordinators at the district level
as well. Finally, back-up support for the volunteers is provided by teams
of health staff from nearby health centres.

A nutritional monitoring system has also been created: At the monthly
weighing sessions, the volunteers fill out forms for all chil dren, recording
their age and weight. The information on the nutritional status of all the
children in a village goes on the form volunteers send every month to the
district health supervisor, who then reports the status of the district's
children to the regional coordinator.

The tangible change for families and children in Al Dakhiliya has been
so positive that the programme is being expanded to additional villages
in the region and has been introduced in another five regions of the country.